HomeMy WebLinkAboutCC 7 CLAIM #86-16 05-19-86AGEND'A.
CONSENT CALENDAR
NO. 7
5-19-86
DATE:
April 29, 1986
Inter-Corn
uT~ :1. '~98~ HGtqORABLE HA¥OR ~D CZ~Y COUNCIL/'
C~Y A~EytS OFFICE
1/13/86~
DA~E FrLBD ~/CI~Y: 4/16/86~ ~AIR NO: 86-16~
R~ FInE NO: S45903R~
After investigation and review it is recommended that the above-
referenced claim Bo rejected and the City Clerk directed to give
proper notice of the rejection to the cl. aimant and to the
claimant's attorney. ~~~
RKE
JGR (F4. se)
Enclosure:
Copy of Claim
('For Damages t'o Pers~i~ -' Personal Prc~p~'{y) ~"~
Rece±ved by
u.s. Mail
Inter-office Mail
Over the Counter
via
The law provides generally that a claim must be £iled with the City Cler~ o]
the City of Tustin within 100 da s after which the incident or event occurr~
Be sure your claim is aga~n~--t~ne City of Tustin, not another public entity
Where space is insufficient, please use additional paper and identify info~
tion by paragraph number. Completed claims must be mailed or delivered to ~
Cit~ Clerk, The Cit~ of Tustin, 300 .Centennial Wa~, Tustin, California 9268~
TO TEE HONORABLE MAYOR AND CITY COUNCIL, City of Tustin, California=
The undersigned respectfully submits the .following claim and information re:
rive to damage to persons and/or personal property:
1. NAME OF CLAIMANT='
a. ADDRESS iF.CLAIMANT=
b. PHONE NO. ( ) -
SOCIAL · DRIVERS
d. SECURITY NO: e. LIC SE
Name, telephone and poet office address to which claimant desires notice
to be sent, if other than above~ ~~;
This claim is Submitted. against~
a. The.City of Tustin only.
b. The following employee(s) of the City of Tustin only=
The City Of Tustin and the following employee(s) of the
Wf Tu.tin only: a~ -' --
4. Occurrence or event from which the claim.arises: .'..
a.
and
spe~n) =
d. BOW and under what circus occur? Speci/
~e particular occu~ence, event, act or omission you claim Caused
~.~ju~ or ~ma~e (U~e addi'~ional paper if necessary). ·
al~e_ged damage o~ injury? _. ~ .. . .
Give a description of tAe injury; Property damage or loss so far as is
known, at the time of this claim. If there were no injuries, stfite "no
injuries".
6. Give the name(s) of the City emPloyee(s) causing the damage or injury:
7. Name..an.d ..address of any other person injured:
8. Name and address of the owner of any damaged property:
9. Damages claimed ~
a. Amount claimed aa of this date: ~ ~:~
b. Estimated amount of f. uture costs:
c. Total amount claimed. ~r ~. ~ '
d. Basis for computation of amounts cl~o_~_.a_~_l bills,
. invoices, estimates, etc.: . ,2~,',/,'I/~,'~ ,
10. Names and addresses of all witnesses, hospitals, ooc:ors, etc.:
b.
d.
1.. Any additional information that might"be helpful in considering this clai~
WARNING: 1T I$ A CRIHINAL OFFENSE TO FIL~. A FALSE CLA'~M'- (Penal Code
Section 72; Insurance Code Section 556.0)
I have read the matters and statements made in the above claim and I know the
same to be true of my own knowledge, except as to those matters stated to be
upon information or belief and as to such matters I believe the same to be tru
I certify under penalt~ of perjury that the foregoing is TRUE AND CORRECT.
/~~ , 19~ , at Tustin, California.
Executed this of '/
C~S SIGNATURE
Office of the Cit~ Clerk,
-ustin, California
No: DAT '
Revised 8/05/81
JGR:se:R:8/5/81 (A)